HomeMy WebLinkAbout0005 COUNTY SEAT STREET - Health 5 COurity Seat-Street
Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection _Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 5 County Seat Street
Property Address
Cynthia Clough
Owner, Owner's Name
information is
required for every y H annis MA 02601 10/5/12
page. City/Town State Zip Code. Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer, f I/
use only the tab 1. Inspector: - -
key to move your
cursor-do not Ricky Wright
use the return Name of Inspector
key.
B & B Excavation,lnc.
Company Name
14 Teaberry Lane
Company Address
r Forestdale MA 02644
Cityrrown State Zip Code
508-477-0653 S14595
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. T_heinsp`e tion
was performed based on my training and experience in the proper function and maintenanc"- f on:sje
sewage disposal systems. I am 'a DEP approved system inspector pursuant tor Section 1.5.340cof
Title 5(310 CMR 15:000). The system:
® Passes 0 Conditionally Passes ❑. Fail
0 Needs Further Evaluation by the Local Approving Authority
-ra
„_..� 10/5/12
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design.flow of 10,000 gpd or greater, the inspector and the system owner shall submit the. .
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only.describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how.the system.will perform in the future under
the same or different conditions of use.
15ins•11/10 TitlViecuon rm:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is required for every Hyannis MA 02601 10/5/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old`or the septic tank(whether metal or not) is structurally
unsound„exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
_ � f
4
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
,M 5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is required for every Hyannis MA 02601 10/5/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below):
I
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed. ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
r ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and.the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is required for every Hyannis MA 02601 10/5/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: ,
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
`•This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
�l
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•11/10_ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
i Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is required for every Hyannis MA 02601 10/5/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes . No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. j
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or j
tributary to a surface water supply.
❑ - ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5-County Seat Street
Property Address.
Cynthia Clough
Owner Owner's Name
requinform
r on is Hyannis MA 02601 10/5/12
requiredd for every y
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
El ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the.system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El Z.
Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ® - Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for.signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
❑ ® approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential.Flow Conditions:
Number of bedrooms(design)::: 4 Number.of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is Hyannis MA 02601 10/5/12
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d n/a
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? 0 Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is required for every Hyannis MA 02601 10/5/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Isnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is Hyannis MA 02601 10/5/12
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
leaching upgraded in 2003
I
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage.
Septic Tank(locate on site plan):
4"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No
Dimensions: 1000 gal
Sludge depth: 12 .
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is required for every Hyannis MA 02601 10/5/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
24"
6"
Scum thickness
5„
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? scour stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. No sign of leakage
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
1
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is required for every Hyannis MA 02601 10/5/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
i
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is Hyannis MA 02601 10/5/12
required-for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box appears to be in good condition.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
I
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is required for every Hyannis MA 02601 10/5/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appears to be in good condition. No sign of hydraulic failure
/
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
. r I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is Hyannis MA 02601 10/5/12
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
J
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
4
t � '
l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title' 5 OfficialInspection Form
Subsurface Sewage-Disposal System Form -Not for Voluntary Assessments
M 5 County Seat Street
Property Address
Cynthia Clough
Owner Owners Name
information..is
required for every Hyannis MA 02601 10/5/12
page. City/Town State Zip Code Date-of Inspection
D. System information.(cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at1east two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ .drawing attached separately
C
B► = �11I
-C a,5
=45 O
E6
o
o
i .
t5ins•11/10 '
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is required for every Hyannis MA 02601 10/5/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
Site Exam:
ti
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >15'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
3/13/2003
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Mrs•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 5 County Seat Street
Property Address
Cynthia Clough
Owner Owner's Name
information is required for every Hyannis MA 02601 10/5/12
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 y Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
-* TOWN OF BARNSTABLE
CATION J Cov r)-4 4 Se-a►•'1" SEWAGE # aDC7 3' O a-
�. VILLAGE )L4 ASSESSOR'S MAP & LOT 29 ` 120
INSTALLER'S NAME&PHONE NO. Ro 6 5 o r-% 5¢62-t' -, �7"7 S- '-7 7 6
SEPTIC TANK CAPACITY 1000
LEACHING FACILITY: (type) 3 5'00!; 1 62/',irnf,QNze) /.)•S 3S'
NO.OF BEDROOMS 3
IUBUILDER•R OWNER GIo c?R
PERMITDATE: �r �-�3 COMPLIANCE DATE: 3- �l- 03
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
U,
' � G
O n F+ +
3s F+
j
No«c � l()Z -- :� � Fee
THE COMMONWEALTH OF MASSACHUSETTS _ Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,,'MASSACHUSETTS
0(ppitcation for Miopogal Opgtem Construction Permit
Application for a Permit to construct( _ )Repair(;)()Upgrade( )Abandon( ) O Complete System O Individual Components
Location Address or Lot No Owner's Name,Address and Tel.No.
SCau.'i Sea-f St/e�t y."11 b 11,4 e/ough
Assessor's Map/Parcel
Install a pddro2s,and Tel.No. Designer's Name,Address and Tel.No.
w. d fir, or1 seotu, Ser40ICer ECo .-fe�h
00,4 /0439 G2?feru;lle�. 43 �Y'i91191�C�r�lc� SA�7XJwic��t
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
'Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) %- 5 ,eGr,rl s y s t'ep
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss e d of Health.
Signed Date
Application Approved by Date 3 !3 3
Application Disapproved for the following reasons
Permit No. 200 3 —1 Z Date Issued ? 0'3
S•. ,.-`._. -,,�. ,ti w,w�,��N y . ;w_.rr.. .. :y =n�. r- . .-. .cr,,. , ..y,•' ti..,f;, .+•'x.. .w"--c�- �'�+ar'•�'TI'"-''#+ r.;i F � _
r4- •, w
1 S
,No.. () Fee �V •oG/
THE COMMONWEALTH OF MASSACHUS•E'TT �(j Entered in computer: Yes
j •. .PUBLIC HEALTH DIVISION"'.
IVISION'=TOWN OF BARNSTABLE,-MASSACHUSETTS
0(ppficatton-for Migpooar bpotem Construction Permit
Application for a Permit to Construct pp" ( . )Repair(XI)Upgrade( %)Abandon( ) D Cofn-plete System El Individual Components
Location Address or Lot No. Owner's Name,Address a ann
d Tel.No.
SC'cu.kl+y $ec-r St/'ect Hy4nn/s �q� A Clou9h
Assessor's Map/Parcel
1 - i O
Installer's Name �q ddress,and Tel.No. 77 _ Designer's Name,Address and Tel.Nd
LU. r— 1�.dljin.Sah Se/�'� Ser u<e• EC o -
` c"GI
�3o/ log9 Cerfi�rv�lle� N3 ��iAny'l C���/� SA'IVk//c.h
Type of Building: `J
Dwelling No.of Bedrooms l Lot Size sq.A. Garbage Grinder(nq
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
' Design Flow \ gallons per day. Calculated daily flow gallons. ,
Plan Date ` Number of sheets y Revision Date
Title
Size of Septic Tank Type of S.A.S.
k• Description of Soil;
Nature of Repairs or Alterations(Answer hen applicable) t k Jl e,ac,v] SV S to h'/
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance,of the afore described on-site sewage disposal system
in accordance with the provisions of Title'5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed Ba der of Health.
Signed Date
Application Approved by Date 3 /3 0 3
Application Disapproved for the following reasons
Permit No. Zp0-3.- I`p Date Issued �xi 3 0
THE COMMONWEALTH OF MASSACHUSETTS x
.0 lGuy6
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS.TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (,�)Upgraded( )
Abandoned( �)by U/ �=. R O 6 1/'I_,�77 h �-
at S GO u vfi`/ J`^�a--r S7`r•e e &/IA t)/s has been construct d in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2-M3—/b2 dated 3 /3 e 3
Installe% Designer dp
The issuance of -his.pe it shall not be construed as a guarantee that the system wil nc n
Date ,3 Z 3 Inspector
No. zoo 3—/OZ Fee 5-O.00
C'1 ou?h THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Miopo!5ar *p.5tem Construction Permit
Permission is hereby granted to Construct( )Repair(1K)Upgrade( )Abandon( )
System located at _ C oa nZt ea-1- S 91-e e?'
�/.91711/S
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Constructio must be completed within three years of the date of this pe t.
Date: . 31f3 03 Approved by
i TOWN OF BARNSTABLE
LOCATION L.t✓v "} --� Se a" SEWAGE # and 3- o
VILLAGE �4 � S ASSESSOR'S MAP & LOT-2-9 ` 17o
y
INSTALLER'S NAME&PHONE NO. RO 6 n 50—
SEPTIC TANK CAPACY I bb D
IT
LEACHING FACILM: (type) 3���;�t �"'/h'� if ze) S y 3S
NO.OF BEDROOMS 3
BUILDER OR OWNER G� a
PERMTT DATE: ' I �i�O 3 COMPLIANCE DATE:. J V- a-3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
+
U.
r
w �¢ 0
y
I
?CO0CAT10 SEWAGE PERMIT NO.31
V I L L AGE i ? :x
INST LLER'S NA ADDARESS
B U I'l D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED '
Fd"
Ah�.
4:4�.
ZM
Ott • • � ..
A2 t
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1VJ ` o ;1aoa CrA�
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. i
h t.,•a�. '. C.EfZT1F l
Ti r EED p t_bT PL./11�1
•' LOCATIdw
G6iZT T►dAT TNt_-I*CA uwDb►T1b�.1 5iaotiutJ 1�t--A►J REFERE�.IGE
%4EQEo44 GOAAPLIeS W tTN T"S 51tM.Ut► C--
A►Jr.> SCTl3ACV-
-To w U oF: N o: 14a3 4 5H;2
DATts
BAX''t"E2 �. u�E tyc_
REG15 iL�tZ�b L..�:4JD SV 2VE`(o VM
TNlS DttAW t5 LJO'T BASeVl - OW AN o5TE2vtLt.E o /j►SS.
tWsTQUMEk.iT SutZvm-{ TNE. AP.PLt CA."-r �eaw�co �2. A-L-r Y
N'bT Bfi USED TO IDe-TEQMtNc-- 1..o-r. Ll"eS
No..-.........T........• _ Fss.... ................
THE COMMONWEALTH OF MASSACHUSETTS
���/]�� �j). BOARD O H.EALTH
......... ....`.....OF.......... . .
,Allplirutiun -fur 13iupuuttl Works Tuttfitrurtiun Vrrntit
Application is hereby`made for a Permit to Construct ( ) or Repair (_� ) an Individual Sewage Disposal
System at: `
rN
- - - ......... -- •--
L ---on.-Addre or,eLo1N ......... �� 7��1� '�'
® Owner
a ............ :272a��--•----------------------- -�----------------------------•� ----- ?7!1
Inst Address.
Q Type of Building Size Lot.--1 X00.....Sq. eedf tr�
U Dwelling—No. of Bedrooms...............3.......................Expansion Attic ( ) Garbage Grinder (40
aOther—Type of Building1WC4_jA* . No. of persons............................ Showers Cafeteria ( )
Q' Other fixtures ------------------------------- --
�
Q ^ --- -----------------------------
--
W Design Flow................t..L?..................gallons per person per day. Total daily flow.........�___fa__0.............gallons.
WSeptic Tank-1 Liquid capacity/.gallons Length................ Width................ Diameter................ Depth---------_......
x Disposal Trench—No_____________________ Width------------- �otal Length.................... Total leaching area....................sq. ft.
Seepage Pit No...../............. Diameter./00q O_( l7epth^ below inle�j............... Total leaching area...................sq. ft.
z Other Distribution box ( ) Dosing tank ( ) 0�_ ;G ` � /6, - 7
Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of "Pest Pit.................... Depth to ground water........................
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
G t� _ �� * -
r -------------------
Description of Soil....................(�------ �`'` ------C ............... -----------------------------------------------
x .:.........................� `V Gl SG =
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
-------------------------------------------------------------------------------------------------•--------------------------....----...------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b • ued by the board health.
a
Stg .d---- - -- ------------ ------. . d
t Date
�i
Application Approved BY C,� = `�/----- 7"-----
7...
Date
Application Disapproved for the following reasons_________________________________________________________________________________________________________________
..................••--------•---•----..................._..-•--------------•-•---•----•-•-•-..._.....-------------------------•-------------------------------------------•---------------------------
t
Date
PermitNo..............................•---...--------------..... Issued........................................................
Date
- r ! �;.
J r l l
l
No........ f....... Ficiz . ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
........... ....OF............ .. ................................................
Applirutiun -fur Bi.gVuottl Workii Tonfitrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:'
.......-- ... 1 ....... .... .. ' --------------- .
c ion-A re / 3 .....ogi`o (.�
w ner es 1 j�,�,
Installers Address
UType of uilding Size Lot.....13,,,.110-0....Sq. feet
., Dwelling=No. of Bedrooms�..�......... .... Expansion Attic ( ) Garbage Grinder (At o
. .. No. of ersolts____________________________ Showers �— Cafeteria
a Other—Type of Building(/�/ _.... p ( ( )
dOther fixtures ......................................................------------------------------------...__......................__......_...._..------......._..
w Desg �b.................gallons per person per day. Total daily flow__________._
ign T•low.........•--_-- �--.�?_.�?-------------gallons.
WSeptic Tank-4Liquid capacity/'I� vgallons Length................ Width................ Diameter................. Depth................
x Disposal Trench—No. .................... Width.___-__--_._.. _ otal Length.................... Total leaching area....................sq. ft.
Seepage Pit No......�------------ Diameter../�.�aITe th below,inle,"____ __________ Total leach area._._.._.__._______sq. ft. .
Z Other Distribution box ( ) Dosing tank ( ) ()�- V;G vl- 7�
Percolation Test Results Performed by------------=---•--............................................_....--_.. Date....................................
Test Pit No. I................minutes per inch Depth of "lest Pit-------------------- Depth to ground water........................
LT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 - _ -fl- =
O Description of Soil G`', -----v�rc '.7 - ...-jr ------ r ._...
----- - -----
--- Cz
x . 0- --------------------------------------------
�., }-• / - =5' � -•---------------------------------------------------------------------
w
U Nature of Repairs or Alterations—Answer when applicable....................................................._._.._.._...-_......_......._..............
--•------------------------------------------------------•-••---------------•---------..._............._.....--•------------•--•-----•-----.._....._....................-----•------------...-----..---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b ss by the board of Ith.
� -----Sig d-------- = ----- - - ---- - ----- - ------------------------ ---
Date-------------•---------
�i Date
Application Approved By..- .. ----- 6�-.- 7 ; '._.. ------a ! 7.
7-7
--
Application Disapproved for the following reasons:................................................................................................................
.............•--••-•------------•-•-•----.._...--•--........-----------....-•-•-•---•---•--------.....---._..........----------------•---------------------............_._._....------....---........-•••
Date
PermitNo----------------------................................... Issued.......................................................
Date
- s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALT
.....� :�.............OF......... .. .... .......................
Tntifirntle of 0WIMpliaurr
T ImS TO rfE FY, 01 t the Individual Sewage Disposal System constructed ( or Repaired ( )
b3 ................................ ........................Y. . ... ..............................................:...............
Installer
.rr
leas been installed in accordance with the provisions of Ar 's 'I of,J11e State anitary Code as descriliw in the
application for Disposal Works Construction Permit No.. /______.__ _'__'............. dated..............��......_._.____...........
THE ISSUANCE OF THIS CERTIFI-CATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION" SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
-76) BOARD OF EALTH
3/ ............ ri`'L'"yi...0F..........:...... 4. .Z.' . .... ...............................
N ........... ----------- FEE........................
i� u rk 11 �Jtillll Permit
Permission i h eby granted_.... = 6�!f'- -
to Con st ct/� 41',brRepair ( dividual S eDr Sal S19tem
at No.- y
Street
as shown on the application for Disposal Works Construction Permit,No �._.....__!..__.. .I�at �._.!`..._��`_.7.�.....
Board of Health
DATE----------------------------------------------------------------------------- C
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
FLOW PROFILE VENT
PIPE
RAISE COVERS TO WITHIN rr
TOP OF FOUNDATION 6 in OF FINAL GRADE
'�:... 'EL - 47.55 +-
ONE INSPECTION RISER FOR
LEACHING GALLERY
1•
2- LAYER OF 1/8'
zf D-BOX 1/2- STONE
�3" DROP H-20
FLOW LINE, TEE
rL
10" 14 H-20 Y
48' GAS�� n PRECAST
BAFFLE Win" r DRYWFI I STONE
6 in `' '" BOTTOM OF ,
43.65+- STONE SOIL ABSORPTION
EXISM6 BASE 40J8 LEACHINGL SYSTEM
EwsTrlo
EXISTING 40.95 40.50 GALLERY
EwsnNo 1000 GALLON 5.00 f► .
(END VIEW) 38.50
EwsnNo SEPTIC TANK 32 11 d) 5 f t 12.5 Ft
6) 13 fr
ESTIMATED 25.90
SEASONAL HIGH.
GROUNDWATER
C1 1 T
0fPA
V"ctlwr E VENUE
n 100 3o ft
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SOIL TEST LOG
DESIGN CALCULATIONS
DATE OF TEST: MARCH 10, 2003 1
SOIL EVALUATOR: DAVID D. COUGHANOWR. RS DESIGN FLOW: 4 BEDROOMS X 110 GPD - 440 GPD
WITNESS REQUIREMENT WAIVED - NO VARIANCES REOUSTED
GROUNDDWATER EN O UNTEREDOUTWASH SEPTIC TANK: 440 GPD X 2 DAYS - 880 GALLONS
TEST PIT I PAR
ELEVATION - 44.30 .- PERC AT 78 in : 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IS SOUND STRUCTURAL
CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED)
DEPTH SOIL USDA SOIL SOL COLOR SOL OTHER DISTRIBUTION BOX: USE H-20 RATED 3 OUTLET D-BOX.
MHES) HORIZON TEXTURE (MUNSELL) MOTTLING
0-10. A LOAMY SAND 10 YR 3/1 NONE FRIABLE SOIL ABSORBTION SYSTEM: A 33.5 ft x 12.5 ft x 2 fi LEACHING GALLERY CAN LEACH
10-40 B LOAMY SAND 10 YR 5/6 NONE FRIABLE A b o t - (33.5 x 12.5 ) - 418.75 s f -
40-152 C MEDIUM SAND to YR 6/4 NONE LOOSE. 5i STONES A s d w - ( 3 3.5 + 3 3.5 { 12.5 ; 12.5 ) x 2 - 18 4.0 s f
Atot - 602.75 sf
Vt 0.74 x 602.75 - 446.03 GPD
USE A 33.5 ft x 12.5 ft x 2 ft GALLERY. .Vt - 446.03 GPD > 440 GPD REQUIRED
GROUNDWATER
ADJUSTMENT LEACHING GALLERY CONSTRUCTION
EXISTING GROUNDWATER LEVEL DETAIL
BASED ON BARNSTABLE GIS
DEPARTMENT RECORDS GALLON CONCRETE 500
GALLON PRECAST DRYWELL
OBSERVED GW: 22.00 LEACHING UNIT OR
INDEX WELL: AIW-230 USEvH-20 UNITS STONE
ZONE: D
8'-5'x 4'-I0"x 2•-9" i
READING: FEB 2003 z f, EFF. DEPTH
LEVEL: 23.4 33.5 f r
ADJUSTMENT: 3.9 ft in
ADJUSTED GW: 25.9
2
NOTES N C. ° ° ° ° LA
N
1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN T
2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 4.0 8.5' 8.5' 8.5' O'
3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS 33.5 ft
OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15)
4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES
BEFORE EXCAVATING FOR SYSTEM.
5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED
i 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE
7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN
8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES
AND APPLIANCES, AND BIANNUAL PUMPING OF THE SEPTIC TANK i SEWAGE DISPOSAL SYSTEM PLAN
9) USE H-20 RATED CHAMBERS AND D-BOX AND LANDSCAPE AREA AROUND SEPTIC TANK ' TO SERVE EXISTING DWELLING
TO PREVENT VEHICLES FROM DRIVING OVER IT.
10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK.
i DANA & CYNTHIA CLOUGH .
1 1) SEPTIC TANKS SHALL BE INSTALLED LEVEL 'AND- -TRUE TO GRADE ON A LEVEL 5 COUNTY SEAT STREET HYANNIS. MA
STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH
SIX INCHES OF CRUSHED STONE HAS BEEN 'PLACED TO MINIMIZE UNEVEN SETTLING
12) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED ECO-TECH ENVIRONMENTAL
FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE,
43 TRIANGLE CIRCLE SANDWICH MA- 02563'
ETE-1369 I MARCH 1 I. 20 33 2/2